Download Improving Apparatus Response And Roadway Operations

Firefighter Rehabilitation at
Emergency Scenes and
Training Exercises
International Association of
Fire Fighters
Occupational Health & Safety
Department
In conjunction with
The United States
Fire Administration
Section 1 - Introduction
Objectives
Course
Stress-related problems account for the leading cause of injuries and deaths to
firefighters. After completing this course, the firefighter should have a greater
awareness of how these risks can be reduced through the implementation of proper
firefighter rehabilitation procedures. These should be used both at actual incidents and
during prolonged practical training exercises. The firefighter will also understand basic
strategies for implementing and improving emergency incident rehabilitation
operations.
Section
After completing this section, the firefighter will show the following competencies by
achieving an acceptable score, as defined by your organization, on the written test or by
any other means of evaluation deemed acceptable by the organization.
Specific
After completing this section, the firefighter will be able to: (Slide 1-2)
1. Define the purpose of emergency incident rehabilitation for the fire service.
2. Explain the dangers of stress-related injuries and deaths as they apply to fireground
operations and training exercises.
3. Identify critical issues from case studies of firefighter injuries and deaths due to
stress-related problems and lack of rehab procedures.
4. Discuss the various laws and standards related to rehab that apply to firefighters.
Time
20 Minutes
Section 1 Outline
Introduction
Explain
that this program was developed by the International Association of Firefighters using
funding provided by the United States Fire Administration. The program has been
distributed to local unions for the purpose of providing information that will increase
the health and safety of all members. The IAFF, the local union, and the administration
of the fire department support finding better ways to ensure that all members go home
healthy at the end of their shifts.
Discuss
incidents where members of this department were injured, killed, or otherwise
incapacitated because of over-stress situations and the lack of a plan to deal with these
issues.
Review
the specific objectives you plan to cover in this section.
Objective
1-1
Outline
Define the purpose of emergency incident rehabilitation
for the fire service.
1. The formal term applied to caring for emergency responders
during incident and training activities is emergency incident
rehabilitation.
Visuals
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2. In daily use this is shortened to simply rehab.
3. The term rehab is used to describe the process of providing rest,
rehydration, nourishment, and medical evaluation to responders
who are involved in extended and/or extreme incident scene
operations.
4. The goal of rehab is to get firefighters either back into the action
or back to the station in a safe and healthy condition.
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Explain the dangers of stress-related injuries and deaths
as they apply to fireground operations and training
exercises.
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1. According to United States Fire Administration statistics,
cardiac- and stress-related events are the leading cause of
firefighters each year. They account for almost half of all deaths
on an annual basis.
2. While they actually account for a low overall percentage of
injuries, when they do occur they tend to be very serious in
nature.
3. The most likely place to incur a thermal injury is on the
emergency scene (on average, 70% occur here).
4. 11% of thermal injuries occur in training.
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5. Rehab is also important in reducing cardiac events. On average,
41% of cardiac events occur on the emergency scene, 24%
during other on-duty activities, and 16% in training.
6. These numbers stress the need to take preventive measures when
engaged in extended emergency and training operations.
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Identify critical issues from case studies of firefighter
injuries and deaths due to stress-related problems and
lack of rehab procedures.
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NOTE TO INSTRUCTOR: Based on class length and preference,
you may choose to delivered either one of both of these case
studies. You may also substitute others from the resource disk.
Case Study #1
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Name: Todd David Colton
Age: 25
Rank: Firefighter
Status: Career
Years of Service: 9 months
Date of Incident: September 6, 1990
Time of Incident: 11:55 hours
Date of Death: September 6, 1990
Weather: Extremely hot, humid, and windy, temperature of 97
degrees and wind at 24 miles per hour, gusting to 35
miles per hour.
On September 6, 1990 just before noon, the Sedgwick County, Kansas
Fire Department was dispatched to a brush fire at the rear of a
manufactured home in a wooded section of the county. The fire began
when an occupant of the home set a trash pile on fire and let it get out of
control. The occupant tried unsuccessfully to control the fire with a
garden hose for about 20 minutes before calling the fire department.
By the time the first fire units arrived, the fire had spread to adjacent
yards and to an auto salvage yard behind the yard of origin. Sedgwick
County Engine 6, staffed by Firefighter Colton and his captain, was the
first unit to arrive on the scene, at 11:55 hours. They maneuvered the
engine behind the house and down an incline close to the fire and began
suppression operations. The captain called for additional units and, as
Command, assigned them to adjacent properties to surround and contain
the fire’s spread. At about 12:20 hours the captain radioed that he and
Firefighter Colton needed relief because they were exhausted. He
radioed for relief again at 12:27 hours and at 12:41 hours.
Another Sedgwick County firefighter arrived in a tanker (tender) and
saw the captain and Firefighter Colton some time between 12:27 and
12:41 hours. That firefighter and a volunteer firefighter on mutual aid
pulled lines from the tanker (tender) and began suppression operations.
When the tanker (tender) ran out of water, the pair left the scene to refill
it. When the tanker (tender) returned to the scene, Firefighter Colton and
his captain were no longer with their apparatus.
By this time, a Sedgwick County assistant chief had arrived and
assumed Command. He could not see or locate the Engine 6 crew. After
several attempts to explain Engine 6’s location to the chief, the captain
decided to go to the command post to accompany the chief into the fire
scene. He instructed Firefighter Colton to remove his personal
protective equipment, get a drink of water, and rest on the rear step of
Engine 6 until he returned with firefighters to relieve them.
The chief had established the command post on the road in front of the
salvage yard. An ambulance was parked next to the command post with
emergency medical technicians standing by to treat injuries or
exhaustion. As the captain approached the command post, exhaustion
overcame him, and the chief ordered him to the ambulance for
rehabilitation. He advised the chief that Firefighter Colton also needed
relief. At approximately 13:35 hours, Firefighter Colton was ordered by
radio to report to the command post and the receipt of the order was
anonymously acknowledged.
At this point, Firefighter Colton and his officer had been working for
approximately 90 minutes in full structural fire fighting protective
clothing including protective trousers, protective coat, gloves, rubber
boots, and a helmet. Firefighter Colton was not wearing a Personal Alert
Safety System (PASS) device.
While the captain was in rehab in the ambulance, a request to assist a
downed firefighter came over the radio. The captain attempted to leave
the ambulance, believing that the downed firefighter was Firefighter
Colton, but the medical quality control officer stopped him. The downed
firefighter turned out not to be Firefighter Colton. When the captain left
rehab, he inquired about Firefighter Colton’s status and was told that he
had been assigned to drive a tanker (tender). The captain was then
assigned as a sector commander and assumed that role in the
suppression operation.
There were conflicting reports that Firefighter Colton visited rehab or
was provided with water by other firefighters some time around 14:30
hours.
Just after 16:00 hours, a volunteer firefighter discovered Firefighter
Colton’s body. Firefighter Colton was still in his full personal protective
clothing in a brush-covered, unburned area which sloped away from the
house of origin. That slope may have prevented other firefighters from
seeing him. He was laying supine on a car wheel and EMS assessment
revealed rigor mortis. The Sedgwick County coroner ruled that his death
was caused by heat stroke.
A NIOSH investigation of the incident cited several factors that
contributed to Firefighter Colton’s death including,
1. The lack of a safety officer on the incident
2. The lack of a coordinated system of rehab between fire and EMS
agencies on the scene
3. The lack of an on-scene accountability system
4. Understaffing of Firefighter Colton’s engine company
5. The lack of a PASS device.
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Case Study #2
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Name: Wayne Mitchell
Age: 37
Rank: Firefighter Recruit
Status: Career
Years of Service: 3.5 months
Date of Incident: August 8, 2003
Time of Incident: 1000 hours
Date of Death: August 8, 2003
Weather: 87 degrees, with 80 percent humidity
On August 9, 2003, Miami-Dade, Florida Fire Department Recruit Class
93 was scheduled to participate in a live burn exercise at the Resolve
Marine Fire School at Port Everglades, Florida.
The facility was a series of shipping containers put together to simulate
a ship; it was not certified by the State Bureau of Fire Standards and
Training, nor was it approved for LP gas use or designated to have any
type of fire outside the burn box. The facility was being used under a
memorandum of agreement with the local fire department because the
Miami-Dade Fire Department did not have an approved burn facility
operational at the time.
The training scenario involved five recruits following a fire hose
through two stories of the ship simulator into a section designated the
fire box, where they took turns operating a nozzle in various patterns
without extinguishing the fire. The firefighter recruits were then
assigned to follow the fire hose through a series of three watertight
hatches and to “duck walk” across an open-grated floor over the engine
room fire, down a ladder and through the simulated engine room. Each
squad of five recruits was accompanied by three instructors who had
walked through and made themselves familiar with the facility. The
recruits were not given the opportunity to walk through the prop prior to
the drill, even though this is a requirement of the NFPA 1403 standard
on conducting live fire exercises.
Firefighter Mitchell was wearing full structural fire fighting protective
clothing, including an SCBA. He was in the fourth group of recruits to
go through the exercise on an extremely hot day. When his squad
arrived at the burn box, one firefighter recruit accidentally sprayed the
fire, causing the intensity to drop. The instructor waited a couple of
minutes to allow the intensity to build again; then he decided that the
squad should have a second rotation at the nozzle. After the first two
recruits completed their second rotation, the incident commander
transmitted a 15-minute time stamp, indicating that it was time for the
squad to begin exiting. Because of the incomplete second nozzle
rotation, the recruits were out of order as they turned around and began
to exit. The lead instructor exited because he was overheated; the second
instructor had already exited because of problems with his SCBA. In the
third compartment, the third instructor had difficulty in getting the
recruits to exit because of confusion over the proper exit order.
Visibility in compartments 1 and 2 was much lower than in
compartment 3, and the instructor and recruits did not follow the fire
hose but went directly across the compartments to the faint outline of
the exit doors.
Once out, the chief instructor asked the incident commander for a
Personnel Accountability Report (PAR). At that point, the instructors
realized that Firefighter Mitchell was missing. The incident commander
alerted staff and began opening all the doors on the second floor.
Instructors from the earlier squads donned their SCBA and entered the
structure. One instructor entered compartment 2 from compartment 1
just as another entered from compartment 3. They both saw Firefighter
Mitchell lying prone next to the hose. His PASS device was not
sounding.
The incident commander, who had just opened to exterior door to
compartment 2, and the first instructor pulled Firefighter Mitchell to the
outside deck and began assessing his condition. They took off his
facepiece and noted the sound of compressed air rushing out. Once his
protective clothing was stripped off, Firefighter Mitchell was found to
be unresponsive with no pulse or respirations and hot to the touch. CPR
was initiated, and cold water and ice rushed to him.
An on-duty firefighter from the neighboring fire department saw
Firefighter Mitchell being pulled from the structure and called his
station’s engine company and medical rescue unit to the scene.
Paramedics with advanced life support equipment arrived and
proceeded with intubation, cardiac monitoring, and intravenous
medications. The medical rescue unit arrived at the local hospital’s
emergency department at 10:30 hours and advanced life support
procedures continued until 10:54 hours, when Firefighter Mitchell was
pronounced dead. The autopsy concluded his death was caused by
cardiac arrhythmia due to exposure to heat.
A NIOSH Fire Fighter Fatality Investigation and Prevention Program
report was prepared on this incident (F2003-28). The report made a
number of recommendations to reduce the future incidence of this type
of death. The recommendations were:
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Ensure the Fire Department's Occupational Safety and Health
Bureau (OSHB) provides oversight on all Recruit Training
Bureau (RTB) safety issues, including live-fire training.

Provide the Training Division, and specifically the RTB, with
adequate resources, personnel, and equipment to accomplish
their training mission safely.

Create a training atmosphere that is free from intimidation and
conducive for learning.

Conduct live-fire training exercises according to the procedures
of the most recent edition of NFPA 1403, Standard on Live Fire
Training Evolutions.

Ensure that Standard Operating Procedures (SOPs) specific to
live-fire training are developed, followed, and enforced.
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Ensure that team continuity is maintained during training
operations.
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Ensure that fire command always maintains close accountability
for all personnel operating on the fireground.
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Ensure coordinated communication between the Incident
Commander and fire fighters.

Equip all live-fire participants, including recruits, with radios
and flashlights.
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Establish an on-scene rehabilitation unit consistent with NFPA
1584.

Report and record all work-related injuries and illnesses.
Discuss the various laws and standards related to rehab
that apply to firefighters.
1. There are a variety of laws, standards, and guidelines that
provide information on the need for rehabilitation and give
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guidance on how to do it.
2. Keep in mind the difference between laws and standards: Laws
are rules of society that have been formally adopted by some
governmental agency, typically referred to as an “authority
having jurisdiction” or AHJ. There are criminal penalties for not
following laws. Standards are consensus positions on some
aspects of a particular area or discipline that are developed by a
group of people with a common interest in that area or
discipline. You may be subject to civil penalties for not
following standards.
3. OSHA requirements are law. All fire departments that respond
to hazardous materials incidents (and virtually all fire
departments do) are bound by the requirements of 29 CFR
1910.120 Hazardous Waste Operations and Emergency
Response.
 Requirement 1910.120(g)(5)(x) requires fire department
operation plans and procedures to address limitations during
temperature extremes, heat stress, and other appropriate
medical considerations.
4. NFPA 1500: Section 8.9 requires fire departments to develop a
systematic approach to rehab operations and to include these
procedures in the department’s SOPs.
 It requires the incident commander to consider the need for
rehab at each incident and to establish rehab operations in
compliance with the SOPs when the need is evident.
 Requires each member on the scene to be responsible for
monitoring their own need and communicating their need to
rehab when it arises
5. NFPA 1584 Recommended Practice on the Rehabilitation of
Members Operating at Incident Scene Operations and Training
Exercises

This document was developed by the NFPA 1500
committee.

It is a comprehensive plan for providing rehab operations
at incident scenes and training exercise. It contains the
following sections:
o
o
o
o
o
Chapter 1 Administration
Chapter 2 Referenced Publications
Chapter 3 Definitions
Chapter 4 Pre-Incident Response
Chapter 5 Rehabilitation Area Characteristics
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o Chapter 6 Incident Scene and Fireground Training
Rehabilitation
o Chapter 7 Post-Incident
Section 2 – Heat Stress and the
Firefighter
Objectives
Section
After completing this section, the firefighter will show the following competencies by
achieving an acceptable score, as defined by your organization, on the written test or by
any other means of evaluation deemed acceptable by the organization.
Specific
After completing this section, the firefighter will be able to: (Slides 2-1 and 2-2)
1. Identify basic heat stress terms and concepts.
2. Describe sources of heat exposure that affect firefighters.
3. Understand the added impact of personal protective equipment on heat stress.
4. Understand the effects of heat stress on the human body.
5. Understand the role of adaptation and acclimatization to environmental conditions and how
they may benefit firefighters.
6. Identify and treat the symptoms of minor heat injuries and illnesses.
7. Identify and treat the symptoms of heat exhaustion.
8. Identify and treat the symptoms heat stroke.
9. Describe various methods for avoiding heat-related injuries.
Time
30 minutes
Section 2 Outline
Introduction
Explain
Firefighters are exposed to many thermal environments, both hot and cold, in the course
of their duties. The firefighter responds to structural and wildland fires as well as other
emergencies including vehicle, industrial, aircraft and marine accidents, hazardous
materials incidents, and search and rescue operations during disasters such as floods,
hurricanes, tornados, blizzards and earthquakes. Exposure to environmental factors is
also experienced during training activities and physical fitness programs. While
environmental conditions can be considered in scheduling training activities, the critical
nature of the firefighters' job often requires prolonged exposure to extreme thermal
conditions during emergency operations. Defining the firefighters' environment is an
important first step in developing effective work practices and strategies for protecting
them from stress-related illnesses and injuries. Of the two environmental extremes to
which firefighters may be exposed, high-heat stress conditions are the more common in
most jurisdictions and the more deadly of the two.
Discuss
The environmental conditions that frequently cause problems in your jurisdiction.
Review
The specific objectives you plan to cover in this section.
Objective
Outline
2-1
Identify basic heat stress terms and concepts.
Visuals
2-3
1. It is important to define some important terms and concepts as
they related to heat stress. In most cases these terms also have
application when discussing cold injuries. This section will focus
on their relationship to heat stress situations.
2. Environmental (ambient) temperature: The measure of how
hot the material or objects surrounding the body are. Measured
in degrees (°) in reference to standard temperature scales such as
Fahrenheit (ºF) or Centigrade (ºC).
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3. Thermal radiation: Occurs between objects of unlike
temperature via invisible infrared rays and is related only to the
difference in temperature between the objects, such as
firefighters' protective clothing and a flame front. Measured by
the rate of heat transferred per unit area per unit time and is
expressed in watts per square centimeter (watts/cm2).
4. Conduction: The transfer of heat by conduction requires direct
contact between materials. Examples relevant to firefighters
include kneeling or crawling on a hot or cold surface or touching
hot or cold objects.
5. Convection: If the conducting medium surrounding the body,
such as air or water, is moving, significantly more heat transfer
can occur than in still conditions. A commonly used example of
convective heat transfer is the Wind Chill Index. A similar effect
occurs at high environmental temperatures. Above about 100ºF,
air movement above 10 mph can significantly increase heat
transfer to the body.
6. Relative humidity is also a contributory factor because it
determines the rate of heat transfer by evaporation. When liquid
water changes to steam or water vapor, heat is dissipated.
Relevant examples include the cooling that occurs from the
evaporation of sweat and the vaporization of water by thermal
radiation from a fire when a fog nozzle is in service. The higher
the relative humidity, the less evaporation can occur to remove
heat.
2-2
Describe sources of heat exposure that affect firefighters.
1. Environmental Heat Exposure: Directly related to interaction
with climatic and seasonal conditions. Simply, it is the weather
you are operating in. Firefighters are subjected to environmental
heat conditions during everything they do.
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2. Fire Exposure: The most critical thermal exposure faced by
firefighters, fire exposure occurs during actual fire suppression
and fire rescue activities. Firefighters face particularly severe
exposures during combustible/flammable liquid fuel and
chemical fires.
3. Long-Term Exposure to Heat: For the vast majority of
municipal firefighters, exposure to extreme heat situations will
occur in limited, short doses. There are several exceptions to
this, including:

Career firefighters who have been involved in training
exercises or repetitive calls during high temperature
conditions.

Volunteer firefighters who work outdoor or otherwise hot
atmospheric jobs and respond to fire calls after extended
periods exposed to heat.

Wildland firefighters who operate for long periods of time
in high temperature conditions and may not be able to
retreat to climate controlled facilities during down periods.
4. The longer the prolonged period of exposure to conditions of
elevated temperature, the greater the chance that personnel will
fall victim to heat-related illnesses and injuries.
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5. Incident Commanders and supervisors must continuously
monitor conditions and personnel for the purpose of taking
action before injuries begin to occur.
6. Clusters of minor heat-related problems must be taken as a
warning sign of impending serious injuries and personnel should
be rotated out of action or otherwise treated to prevent the
situation from worsening.
7. Even if the heat problems were on a previous day, the
cumulative effect of the heat build-up could increase the chance
of serious problem on this new day.
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Understand the added impact of personal protective
equipment on heat stress.
1. Almost all firefighter duties require the wearing of special
personal protective equipment (PPE) in order to keep the
firefighters safe. This includes standard fire fighting turnout gear
for structural fire attack or chemical protective clothing for
hazardous materials operations.
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2. All of these increase the level of heat stress on the people that
wear them. Simply stated, PPE inhibits the transfer of heat
between the firefighter and the external environment.
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3. In cold atmospheres this works to our advantage, as the PPE
keeps the body heat trapped within and helps keep the firefighter
warm. However, in high heat conditions it increases the thermal
strain on the wearer’s body exponentially
4. NFPA and OSHA requirements dictate minimum performance
requirements for PPE in relation to protecting wearers during
fire conditions. This is to protect against the severe environment
that is faced when engaging in fire fighting operations.
5. The clothing does also interfere with heat dissipation during
non-fire exposure such as overhaul, hazardous materials
incidents and rescue operations. Heat dissipation is inhibited by
two means:
6. The insulation represented by the clothing reduces heat loss by
convection, conduction and radiation.
7. If clothing is not water vapor permeable (breathable), body
cooling by evaporation of perspiration cannot occur.
8. Significant progress on improving PPE and making it safer to
wear has been made through the years. The first major effort was
the Project FIRES research in the 1970’s that led to the style of
turnout clothing we wear today. A new project called Project
HEROS is currently underway to research this issue even further
and to include chemical protective features to modern turnout
clothing as well.
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Understand the effects of heat stress on the human body.
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1. Physiological Effects
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Humans are warm-blooded
Body burns fuel to try and maintain a normal level of heat (98ºF,
on average); temperature regulation is controlled by the brain.
Temperature controls are activated when the body temperature
deviates from the normal range.
The person will be impaired if their temperature drops below
95ºF; they may go into cardiac arrest if it increases above 105ºF.
An individual’s physical condition will impact how well they
handle heat. People in poor physical condition and with high
body fat tend not to do well in high heat conditions.
Heat stress and dehydration are also linked. In most cases a
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person suffering from heat related symptoms is also dehydrated.
2. Psychological Effects
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Firefighters who are used to, or like, working in hot weather will
not be affected as quickly as those who are not used to it or do
not prefer those conditions.
Regardless of preference, eventually heat stress will reduce
mental performance at some point.
Heat stress slows reaction time and decision time.
Tasks that require attention to detail, concentration, and shortterm memory and are not self-paced may degrade from heat
stress.
Routine tasks are done more slowly and errors of omission are
more common.
Army research shows that dehydration greater than 2% of body
weight will adversely affect mental function of simple tasks.
3. Increased risk factors for heat-related illnesses:
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Dehydration and salt depletion
Lack of heat acclimatization
Poor physical fitness/excessive body weight
Skin problems – Skin irritations such as rashes, prickly heat,
sunburn, and poison ivy will increase a person’s susceptibility to
internal heat illness.
Minor illness – Firefighters who were already suffering from a
minor illness, inflammation, or fever will have an increased
chance of heat injury due to a previously compromised
autoimmune system.
Medications, both prescription and non prescription – Certain
medications will impact the body’s hydration level.
Chronic disease – Diseases such as diabetes mellitus,
cardiovascular disease, and congestive heart failure
Recent alcohol use – Recent alcohol use can impair the person’s
judgment and will also increase the likelihood of dehydration.
Prior heat injury – Heat stress and injuries are additive and can
take a long time to fully recover from. Future exposures to high
heat situations may result in expedited heat injury or illness.
Age – U.S. Army research shows that people over 40 years of
age, even those in relative good physical condition, have an
increased potential for heat illness versus people who are under
that age.
Highly motivated people – People who are highly motivated and
committed to performing given tasks at all costs may overlook
the signs of heat illness and increase their chance of
overextending themselves
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Genetics – People who have genetic mutations, such as cystic
fibrosis and malignant hyperthermia
Understand the role of adaptation and acclimatization to
environmental conditions and how they may benefit
firefighters.
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All humans are basically equipped the same way.
However, we adapt to the environments in which we live.
We are capable of adapting to new environments over a period
of time.
The process of adapting to environmental extremes is often
referred to as acclimatization.
Acclimatization is becoming more important today because
young people do not spend as much time outside growing up as
in previous generations. They may not be used to working in
high heat situations.
Fire departments should have a program to ensure that their
personnel are prepared to deal in the heat conditions that are
likely to be encountered in their jurisdiction. Information on heat
acclimatization programs is included in the USFA Rehab report.
Personnel who are properly acclimatized will be less susceptible
to heat related injuries and deaths.
Identify and treat the symptoms of minor heat injuries
and illnesses.
1.
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The three most common types of minor heat illnesses are: miliaria,
heat syncope, and heat cramps.
2. Miliaria (prickly heat)
 An acute inflammatory disease of the skin.
 The sweat ducts become plugged, and a rash appears.
 Might occur after wearing personal protective clothing.
 Falls more into the category of being annoying rather than
debilitating. Prevention of miliaria can be achieved by resting in
a cool place for portions of the work cycle, by bathing and
drying the skin, and changing regularly into clean, dry clothes.
3. Heat syncope
 Usually occurs in individuals who are not accustomed to hot
environments and who have usually undergone prolonged
standing, usually with the knees straight and locked.
 Heat can cause dilating of large blood vessels and pooling into
the lower extremities. This result is lesser blood flow to the brain
and causes fainting.
 Once supine, the individual usually recovers.
 The patient can prevent further fainting by moving around and
thereby preventing further pooling.
4. Heat cramps
 Most commonly occur during strenuous activity in a hot
environment. Excessive sweating which results in loss of
electrolytes (especially sodium)
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Cramps typically affect the voluntary muscles of the extremities
and in some cases the abdominal wall (side stickers).
Body temperature is usually normal unless the cramps are
accompanied by heat exhaustion.
Heat cramps respond well to rest in a cool environment and
replacement of fluids by mouth.
Heat cramps should be recognized as an early warning sign of a
potentially more serious situation if caution is not exercised.
Heat cramps are usually relieved by rest and replacement of salt
and water lost from the body.
Saline solution (0.1%) by mouth and/or saline solution (0.9%)
intravenous should be administered with the route of saline
administration determined by local procedure and regulations.
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Identify and treat the symptoms of heat exhaustion
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1. Heat exhaustion occurs when excessive sweat loss and inadequate
oral hydration cause depletion of the body’s fluid volume.
2. While heat exhaustion is often related to excessive dehydration, it
can also occur from fatigue and overheating alone.
3. Symptoms of heat exhaustion many include any of the following:
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Fainting
Profuse sweating
Headache
Tingling sensations in the extremities
Pallor (ashen color of the face)
Dyspnea (shortness of breath)
Nausea
Vomiting
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4. Heat cramps may or may not be present with heat exhaustion.
5. Victims will typically reveal a mild to severe peripheral circulatory
collapse with a pale, moist, cool skin and a rapid (100-200
beats/minute), thready pulse.
6. Blood pressure may be elevated prior to onset but could drop to
normal by the time of examination.
7. Oral temperature may be sub-normal due to hyperventilation or
slightly elevated, but the rectal temperature is usually slightly
elevated (99-104°F).
8. If signs are not recognized and treated, heat stroke may occur.
9. Treatment:
 Elevate the patient's legs and remove from the heat to a cool
place.
 Water and/or salt replacement should be undertaken as described
above for heat cramps.
 When at all possible, replacement of fluid using intravenous
methods should be used.
 Continuous monitoring of the patient's condition in the field and
subsequent evaluation of the patient's electrolyte status at a
hospital emergency department should be mandatory.
 Recovery from heat exhaustion is usually rapid, but immediate
return to duty is not advisable.
2-24
2-8
Identify and treat the symptoms heat stroke.
2-25
1. Heat stroke victims have a high probability of permanent
disability or death as a result of this injury.
2. Heat stroke results when the body's temperature regulating and
cooling mechanisms are no longer functional.
2-26
3. Immediately prior to onset of heat stroke, fainting,
disorientation, excessive fatigue and other symptoms of heat
exhaustion may be present.
4. Onset of heat stroke may be rapid with sudden delirium, loss of
consciousness and convulsions occurring.
5. The skin is hot, flushed and dry, although the skin may be wet
and clammy in later stages of the condition when shock may be
present.
6. Rectal temperatures associated with heat stroke are elevated,
frequently in excess of 106°F.
7. Pulse is full and rapid, while the systolic blood pressure may be
normal or elevated and the diastolic pressure may be depressed
to 60 mm Hg or lower.
8. Respirations are rapid and deep.
9. As a patient's condition worsens, symptoms of shock including
low blood pressure, rapid pulse, and cyanosis occur.
Incontinence, vomiting, kidney failure, pulmonary edema and
cardiac arrest may follow.
10. Treatment:
 Even if effective treatment is initiated and the patient
survives the initial episode, severe relapses can occur for
several days.
 Lower the body's temperature as rapidly as possible.
 Active cooling of heat stroke patients can reduce
mortality rates from 50% to 5%.
 The patient's clothing should be removed.
 If cold or ice water is available, the patient should be
doused with and/or immersed in the water.
 An effective alternative is to cover the nude patient with
a cotton sheet, continuously douse the sheet with water
from a booster line or garden hose, and fan them with an
electric smoke ejector.
 Cold packs should be applied to the carotid arteries on
the sides of the neck.
2-27
2-28




The patient's legs should be elevated in a shock recovery
position.
Patient transport to a hospital emergency department
should be initiated as soon as possible.
Normal saline (0.9%) should be cautiously administered
intravenously, if advanced life support providers are
available.
Oxygen should be administered if cyanosis, pulmonary
congestion, or breathing difficulty is present.
2-9
Describe various methods for avoiding heat-related
injuries.
2-29
1. We cannot change the environment in which we operate. We must
adapt to it.
2. Fire departments must have and enforce aggressive policies for
preventing and managing the impact of high heat stress conditions.
3. The general physical condition of the individual has a significant
bearing on their reaction to heat stress.

The risk of heat injury is much higher in overweight, unfit
firefighters than in fit ones.

Physical fitness programs designed to develop both
cardiovascular and muscular fitness can be of great benefit in
reducing heat casualties, although fit firefighters will have their
limits as well.
4. Acclimatization programs can better prepare their personnel to more
effectively and safely operate in high heat conditions.

The major part of this acclimatization process is thought to be
due to increased effectiveness of the sweating mechanism

Any physical fitness or acclimatization training must be
coordinated with the departmental and firefighter's personal
physician and managed with great care.

A firefighter experiencing abnormal fatigue, dizziness, nausea or
other signs of stress must not be forced beyond his capacity or
heat injury may result.

Drills and exercise should be carefully monitored when
Apparent Temperature exceeds 90°F and modified or suspended
when Apparent Temperature exceeds 105°F.

If turnout clothing is worn, an adjustment factor of 10°F should
be added to the environmental temperature before the Apparent
Temperature is calculated.
5. The most critical factor in prevention of heat injury is proper
hydration.
 Water must be replaced, both during exercise periods and at
emergency scenes.
 Thirst should not be relied upon to stimulate drinking.
 Cool water and cups must be readily available at both exercise
areas and emergency scenes and drinking encouraged.
2-30
2-31
2-32

More detailed information on prehydration and hydration for
firefighters is covered in Lesson 5.
6. Proper rehabilitation procedures will also dramatically reduce the
chance of heat related illnesses. These will be covered in more
detail later in this program.
Section 3 – Cold Stress and the
Firefighter
Objectives
Section
After completing this section, the firefighter will show the following competencies by
achieving an acceptable score, as defined by your organization, on the written test or by
any other means of evaluation deemed acceptable by the organization.
Specific
After completing this section, the firefighter will be able to: (Slides 3-1 and 3-2)
1. Explain the terms and concepts associated with cold weather factors and stress on
firefighters.
2. Understand the firefighter’s physiological response to cold weather conditions.
3. Recognize the signs of hypothermia and initiate the proper treatment.
4. Recognize the signs of frostbite and initiate the proper treatment.
5. Recognize the signs of immersion injuries and initiate the proper treatment.
6. Recognize the signs of chilblains and initiate the proper treatment.
7. Describe the guidelines for the prevention of cold injuries.
Time
25 minutes
Section 3 Outline
Introduction
Explain
Although historically extreme heat has been the most problematic of climatic conditions
for firefighters, fire departments in jurisdictions subjected to cold weather must also
recognize the impact that these conditions will have on their firefighters and operations.
These departments must develop plans to deal prolonged exposures to extreme cold
temperatures during the course of training or emergency scene operations. While the
threat of a systemic illness (comparable to heat exhaustion or heat stroke) is more
remote in cold weather, there is an equal or greater chance for other injuries, such as
frostbite and injuries as a result of slips and falls.
Discuss
the impact (if any) cold weather conditions have had on emergency operations within
your jurisdiction in the past.
Review
the specific objectives you plan to cover in this section.
Objective
3-1
Outline
Visuals
Explain the terms and concepts associated with cold
weather factors and stress on firefighters.
3-3
1. Most areas of North America experience cold-wet conditions at
some time during the year. Cold-wet conditions are characterized
by environmental temperatures of between 14°F and 68oF.
Temperatures can change rapidly and daily freeze/thaw cycles can
occur. Precipitation in the form of rain, freezing rain, sleet or snow
can be regularly experienced.
3-4
2. Cold-dry conditions are characterized by environmental
temperatures of less than l4°F. Below-zero and windy conditions
are often experienced in these areas. The colder that air becomes,
the less moisture it is capable of holding, thus many of these areas
tend to be rather arid and any precipitation they doe receive is in the
form of dry, powdery snow.
3. The combination of cold air and humidity is not an issue for
firefighters. This is primarily due to the fact that as air gets colder
its ability to contain water in suspension is reduced.
4. More troubling is the combination of cold and wind.
 The presence of wind increases the transfer of heat away from
the person’s body.
 Although the environmental temperature is at a certain degree,
the person loses body heat a rate that is comparable to a lower
actual temperature in the absence of wind. This effect is
commonly referred to as the Wind Chill Index.
5. The current Wind Chill Index is based on the following criteria:
 Wind speed is calculated at an average height of 5 feet from the
ground, the average height of a human head, on the basis of
wind speed readings taken from standard anemometers, which
are typically mounted 33 feet from the ground.
 The factors are based on a human face model and a standard skin
tissue resistance.
 The latest information in human heat transfer theory was used.
 Winds between 0 and 3 miles per hour (5 km/h) are considered
to be calm.
3-5
3-6

3-2
The wind chill chart assumes no impact from the sun.
Understand the firefighter’s physiological response to
cold weather conditions.
1. Cold weather conditions can have implications that influence the
health and safety of firefighters and emergency operations:
 Food and water requirements may be higher than expected, as
people burn more calories in cold weather
 Maintaining proper field sanitation and personal hygiene in
rehab operations is more difficult.
 Sick and injured individuals are susceptible to medical
complications produced by cold.
 Operational problems often arise in cold weather, including
physical performance decrements, equipment malfunctions, and
slow movement of vehicles and personnel.
2. Convective heat transfer will impact firefighters.
 Wind will increase body temperature loss as it blows across the
firefighter.
 If the firefighter is wet or wading in water, heat loss from the
body may be accelerated by as much as 25 times.
3-7
3-8
3-9
3. Radiative heat loss is not a big issue in cold weather. Radiation
mostly helps in the form of sunlight.
4. Conductive heat loss is most likely to occur when operating/laying on
cold ground/snow and touching metal objects or liquids. Heat loss
will be accelerated if the firefighter is wet.
5. Evaporative heat loss occurs when liquid turns to water vapor.
 Evaporative heat loss is associated with sweating and
respiration.
 When firefighters perform strenuous exercise in heavy clothing,
significant heat strain and sweating can occur.
 After exercise, the nonevaporated sweat will reduce clothing
insulation capabilities and possibly form ice crystals.
6. The key to effective operations on cold weather conditions is
maintaining effective behavioral temperature and physiological
temperature regulation.
 Behavioral temperature regulation refers to conscious actions we
take including things such as wearing appropriate clothing,
seeking shelter, and avoiding cold conditions.
 Physiological temperature regulation refers to the body’s natural
reaction to minimizing the impact on cold conditions. Two
common physiological responses are reduced blood flow
(vasoconstriction) to conserve the body’s heat and shivering to
produce additional heat.
3-10

Of the two metabolic methods for producing heat, physical
movement will generate more heat than shivering.
7. There are a variety of individual factors that influence the effect of
cold exposure on a particular person.
 Body size and fat – People who have long and lean body types
will lose heat faster than those who have short or stocky body
types.
 Gender – Records kept by the United States Army show that
women have a periphery cold injury rate that is twice that of
males.
 Race – Again, records and research conducted by the Army
shows that black soldiers were two to four times more likely to
suffer a cold weather injury than their Caucasian counterparts.
 Fitness and Training – The level of fitness in the individual has
little impact on the physiological response to cold stress.
 Fatigue – Physical fatigue will impair shivering and peripheral
vasoconstriction during cold exposure.
 Age – Army research showed that people older than 45 years of
age were less cold tolerant than younger people
 Dehydration – Dehydration can increase susceptibility to cold
injury by decreasing the ability to sustain physical activity.
 Sustained operations – Exertional fatigue, sleep deprivation, and
poor nutrition (underfeeding) are common stressors during
sustained operations and will impair the firefighter’s ability to
maintain thermal balance in the cold.
 Alcohol – Although alcohol may impart a sense of warmth, any
peripheral vasodilation (which alcohol causes) will increase heat
loss and the risk of hypothermia. It also impairs judgment and
reduces the ability to feel the signs and symptoms of impending
cold injury.
 Nicotine – Smoking or chewing tobacco can increase
susceptibility to frostbite by increasing vasoconstriction in
peripheral body parts, such as the hands.
8. When looking at the effects of cold on performance, there are three
particular areas that must be considered: ability to work/exercise,
manual dexterity, and cognition/thinking.
 Exercise performance is not altered as long at the body core
temperature drop is less than 0.9ºF and the muscle temperature
remains above 97ºF. However, for every 1.8ºF decrease in core
or muscle temperature, maximal endurance exercise capability is
lowered by about 5%, exercise endurance time is lowered by
20%, and maximal strength and power output is lowered by 5%.
 Manual dexterity declines 10-20% after finger skin temperatures
decrease below 60ºF. Tactile sensitivity is reduced as skin
temperature drop below 43ºF and further sharp decline in finger
dexterity occurs at this point
3-11
3-12

The ability to remember new information is impaired when the
body core temperature falls between 94 and 95ºF and short-term
memory declines up to 20% with significant peripheral cooling
absent of a decreased body core temperature.
9. When considering predisposing factors that may impact a
firefighter’s susceptibility to hypothermia, there are four categories
of factors that must be considered:




Those that decrease the person’s ability to produce heat. These
can include inactivity, fatigue, excessive energy depletion, and
problems affecting endocrine levels, such as hypopituitarism,
hypoadrenalism, hypothyroidism, hypoglycemia, and diabetes.
Those that increase a person’s heat loss. These include wet
clothing, immersion in water, excessive sweating, exposure to
wind, fatigue thermal burns, sunburn, and various forms of
dermatitis.
Those that impair the body’s ability to thermoregulate.
Peripheral failures can be cause by trauma, neuropathies, and
acute spinal cord transaction.
Other miscellaneous clinical conditions, including infections,
renal failure, and cancer.
10. The predisposing factors for frostbite and localized cold injuries
can be categorized into five basic categories. These are summarized
as follows:
 Those that decrease the person’s ability to produce heat. These
can include inactivity, fatigue, excessive energy depletion, and
problems affecting endocrine levels, such as hypopituitarism,
hypoadrenalism, hypothyroidism, hypoglycemia, and diabetes.
 Those that increase a person’s heat loss. These include wet
clothing, immersion in water, excessive sweating, exposure to
wind, fatigue thermal burns, sunburn, and various forms of
dermatitis.
 Those that impair the body’s ability to thermoregulate.
Peripheral failures can be cause by trauma, neuropathies, and
acute spinal cord transaction.
 Other miscellaneous clinical conditions, including hypotension,
atherosclerosis, anemia, sickle cell disease, diabetes, shock, and
vasoconstrictors.
3-3
Recognize the signs of hypothermia and initiate the
proper treatment.
3-13
3-14
3-15
1. Hypothermia is a subnormal temperature within the internal body
core.
 A person suffering from hypothermia will exhibit poor
coordination, will often stumble, may slur speech, and suffer
from mental dulling with impairment of judgment and ability to
work.
 Once severe shivering occurs the victim may not be able to
rewarm without an outside heat source.
 Hypothermia depresses normal circulation and vital signs, thus
measurement of heart rate, pulse and blood pressure may be
difficult or impossible.
2. Recommended Treatment:
 Hypothermia that has progressed to the point that shivering has
stopped is a true medical emergency.
 The patient should be evaluated with extreme care, since blood
pressure and radial pulse may not be detectable due to decreased
circulation in the extremities. In fact, the patient may even
appear to be dead.
 All suspected hypothermia patients should be rewarmed at a
hospital emergency department before death is assumed. A
hypothermic patient is not pronounced dead until they are “warm
and dead.”
 Protect the victim from further cold stress by removal to a warm
place.
 Damp, frozen or constricting clothing should be gently removed
and replaced with blankets or other insulation.
 Particular care should be taken to insulate the head and neck
with towels or other material.
 Cardiac arrest may be initiated by rough handling or attempts at
field rewarming utilizing external techniques such as electric
blankets, hot packs, hot water bottles or baths.
 The application of warm, humidified air by mouth-to-mouth
breathing or special warmed air/oxygen respirators can be
effective at stabilizing patients until rewarming can be
implemented in a hospital emergency department.
 You may administer intravenous solutions that have been
warmed before infusion by placing the bag next to a paramedic's
body or in a warm water (98.6°F) bath. If the IV cannot be
started quickly, do not delay transport.
 If the patient is in cardiac arrest, CPR should be implemented in
accordance with normal procedure.
3-4
Recognize the signs of frostbite and initiate the proper
treatment.
3-16
3-17
3-18
3-19
1. Frostbite is a soft-tissue injury resulting from exposure to
environmental temperatures of less than 32°F.
 Injury results from freezing of cell and tissue fluids which
mechanically and/or physically disrupt cellular function.
 General symptoms include sensation of coldness, followed by
numbness. The skin turns red, then pale or waxy grey-white.
2. Superficial frostbite, or frostnip, involves only the skin and/or tissue
immediately beneath it.
 Skin is waxy gray-white with yellow splotches possible.
 After thawing, general swelling will occur and blisters may form
after 24 hours.
 As swelling subsides, the skin usually peels, remaining red and
tender.
3. Deep frostbite involves not only the skin and subcutaneous tissue,
but also deeper tissue down to the bone.
 It is manifested by a persistent lack of effective circulation with
resultant ischemia and cyanosis.
 Skin is translucent, waxy, pallid and yellowish in color. The
tissue is solid to touch and not movable over joints and bones.
 There is a lack of pain while frozen, but after thawing, a
throbbing, aching pain develops often followed by a period of
sensation loss.
 Large blisters usually develop in about 72 hours and the area
will generally be very swollen for a month or more.
 Deep frostbite cases almost always require extensive medical
care.
4. Recommended Treatment
 The patient should be protected from further cold exposure by
removal to warm place.
 Carefully remove and damp, frozen or constricting clothing and
replace with blankets or other insulation.
 In cases of minor superficial frostbite where only the outer layer
of skin is affected, the area can be rewarmed by gently covering
with a hand.
 Do not rub, massage or apply ice or direct heat, such as from hot
packs or from an open fire or apparatus exhaust.
 All cases of frostbite should be protected with a dry, sterile
dressing and evaluated by a hospital emergency department.
 If the injury is to feet or legs, patient should be handled as a
stretcher patient to prevent further injury.
3-5
Recognize the signs of immersion injuries and initiate the
proper treatment.
3-20
3-21
3-22
3-23
1. Immersion injuries, such as trench foot, result from prolonged
exposure to cold at temperatures that do not cause actual freezing.
 This results from compromise of circulation, especially in the
extremities, by various means including local cooling, general
body cooling, constriction by clothing such as gloves, socks or
boots.
 Immersion injuries are not likely to be found in firefighters who
are involved in standard fire fighting operations.
 It is more likely to be encountered in personnel who are
deployed to extended operations, such as major urban search and
rescue operations that last for days at a time.
2. Recommended Treatment
 Personnel should not use the affected area.
 Boots or clothing covering injured area should be carefully
removed and the area gently dried, elevated and protected by a
dry, sterile dressing.
 Do not be rub, massaged moisten or expose the area to ice or
direct heat such as from hot packs or apparatus exhausts.
 Blisters should not be ruptured.
 Patient should be protected from further cold exposure by
removal to a warm place and immediately replacing damp,
frozen or constricting clothing with blankets or other insulation.
 If the injury is to the feet or legs, patient should be handled as a
stretcher patient to prevent further injury.
 All immersion injury cases should be evaluated by a hospital
emergency department.
3-24
3-25
3-6
Recognize the signs of chilblains and initiate the proper
treatment.
1. Chilblains are areas of skin, usually on the face or hands where
circulation has been impaired for some time.
 The condition results from repeated or prolonged exposure to
temperatures above freezing, especially when accompanied by
high humidity.
 Affected skin appears pale and blanched.
 Upon rewarming, the area is red, swollen, hot, tender and itchy.
 Skin may blister or ulcerate.
3-26
3-27
2. Recommended Treatment
 The area should be rewarmed slowly by the bare hand or at room
temperature.
 Do not rub, massage or apply direct heat or ice.
 Itching may be relieved by application of a moisturizing
ointment.
 In severe cases where blister formation occurs, the affected area
should be protected with a dry, sterile dressing and evaluated by
a physician.
3-7
Describe the guidelines for the prevention of cold
injuries.
3-28
1. As mentioned previously, cold injuries are less common than heat
injuries because our protective clothing provides warmth.
2. Provide firefighters with proper PPE for the environment.
 Standard turnout clothing is effective.
 In cold weather jurisdictions, special equipment such as mittens,
helmet liners, wool undergarments, and other cold weather gear
may be issued.
 Carry extra gloves, hoods, and other equipment on apparatus
and have personnel change out of wet gear at the scene.
 Have proper provisions in the station to dry equipment properly.
3. Another critical problem that must be considered in cold weather
applications is the effect of perspiration.
 Under periods of heavy work greater amounts of perspiration are
emitted.
 Much of the perspiration is absorbed by the clothing next to the
skin, then transferred to the outer clothing by a process known as
“wicking”. Trapped moisture has several effects. First, the
insulation value of the clothing layers is impaired due to matting
of the fabrics and filling of the insulating air spaces with water.
Second, if high heat conditions are encountered, this trapped
moisture may be converted to steam, causing burns.
 Advances in breathable protective clothing liners, such as those
3-29
utilizing Gore-Tex™ vapor barriers, have reduced the effect of
moisture building up on the firefighter’s skin.
4. Protecting the head, hands, and feet are most important for
firefighters.
 May need full helmet liners in very cold weather. Replace them
when they become wet. Standard fire fighting protective hoods
may not provide protection against wind or water.
 Firefighting gloves are not designed for cold weather
operations, per se. apparatus should carry extra gloves that
allow firefighters to change out when theirs become wet.
 Boots do a good job of protecting against cold and water, but
must also be replaced if they do become wet inside them. Extra
heavy socks can help in cold weather.
5. Keys to avoiding hypothermia:
 Dress in layers, appropriate to the given conditions.
 Remove some layers, if safe to do so, when doing heavy work.
This will prevent excessive sweating.
 Stay dry.
 Wear your helmet or another hat at all times when in the cold.
 Avoid working in standing water, rain, or overspray from
hoselines, when possible.
 Rotate from operational positions to rest/rehab positions on a
frequent basis.
6. Firefighters need to remember the acronym, COLD, for operating in
cold weather and avoiding hypothermia:




3-30
3-31
3-32
Keep it Clean – The dirtier clothing is, the less it will protect
against cold weather.
Avoid Overheating – Firefighters who overheat and sweat
excessively will ultimately be more susceptible to hypothermia.
Wear it Loose and in Layers – Air insulation between the layers
of clothing is the most effective insulation. It also allows for
adjusting the amount of clothing if conditions warrant it.
Keep it Dry – Water causes cooling 25 times faster than dry air.
Replace wet clothing when extended operations are required in
cold weather.
7. Keys to avoiding frostbite:
 Monitor wind chill temperature and the ambient temperature.
Frostbite can occur any time the ambient temperature is below
32ºF.
 WCTs of -10ºF and below are particularly dangerous for fingers
and ears.
 Wear dry equipment.
3-33




Avoid excessive sweating.
Encourage members to monitor each other.
Cover exposed skin.
Rotate to rehab more frequently.
Section 4 – Establishing and
Operating a Rehab Area
Objectives
Section
After completing this section, the firefighter will show the following competencies by
achieving an acceptable score, as defined by your organization, on the written test or by
any other means of evaluation deemed acceptable by the organization.
Specific
After completing this section, the firefighter will be able to: (Slide 4-1)
1. Explain when it is appropriate to establish rehab operations based on the type of
incident or weather conditions.
2. Describe where rehab operations fit into the Incident Command System.
3. Select an appropriate site to establish rehab operations.
4. List the necessary components for a rehab operation.
5. Describe the types of facilities or apparatus that may be used for rehab operations.
6. List all of the types of equipment that may be used in rehab operations.
Time
30 minutes
Section 4 Outline
Introduction
Explain
that ensuring that firefighters are in good physical condition, properly hydrated, and
well-fed prior to responding to an incident is certainly important in helping to ensure
their safety during operations. However, even physically fit firefighters can suffer the
consequences overexertion and exposure to harsh environmental conditions during the
course of emergency operations and extended physical/practical training activities. Most
of the illnesses and injuries discussed to this point in the document can be avoided by
establishing and operating a proper emergency incident rehabilitation, or rehab, area.
Discuss
incidents that the firefighters have encountered where overexertion and lack of proper
rehab operations affected the incident and their well-being.
Review
the specific objectives you plan to cover in this section.
Objective
4-1
Outline
Explain when it is appropriate to establish rehab
operations based on the type of incident or weather
conditions
1. There are no set criteria or rules for when to establish rehab.
 NFPA 1584 states that procedures should be in place to ensure
that rehab operations commence whenever emergency
operations pose the risk of pushing personnel beyond a safe
level of physical or mental endurance.
 Each jurisdiction should establish its own criteria.
 Even these criteria may have to be adjusted based on given
conditions.
 Don’t play catch-up; be proactive.
 The recommendations below are just that, recommendations.
2. Structure Fires:
 Some departments do it by alarms (i.e.: establish rehab on a 2nd
alarm). This may need to be adjusted in severe weather
conditions.
 NFPA 1584 recommends:
Guideline #1: The company or crew must self-rehab (rest
with hydration) for at least 10 minutes following the
depletion of one 30-minute SCBA cylinder or after 20
minutes of intense work without wearing an SCBA. The
company officer or crew leader must ensure that all assigned
members are fit to return to duty before resuming
operations.
Visuals
4-2
4-3
4-4
Guideline #2: The company or crew must enter a formal
rehab area, drink appropriate fluids, be medically evaluated,
and rest for a minimum of 20 minutes following any of the
following:
o Depletion of two 30-minute SCBA cylinders
o Depletion of one 45- or 60-minute SCBA cylinder
o Following 40 minutes of intense work without an
SCBA

Keep in mind that heavy work occurs during overhaul. Don’t
shut down rehab too early.
3. High-Rise Fires
 Require more personnel to handle than do smaller buildings.
Most departments use a 3-to-1 ratio. 3 companies to accomplish
4-5




what 1 company can accomplish at ground level
Require more energy just to reach the fire area than on low-rise
buildings.
Must establish rehab at all working high rise fires.
Minor rehab may be performed on the Staging floor.
Full rehab operations should be somewhere below that level.
4. Wildland Fires
 In large wildland fires, firefighters will have to rely on selfrehab for extended, remote operations.
 Estimate the size of the fire and the amount of time that will be
needed to completely extinguish it. The IC should establish a
rehab operation when the fire will involve heavy manual labor
for more than 40 minutes.
 Consider the weather conditions at the time of the fire. The
hotter and more humid the weather is, the greater the need for
early rehab operations.
 Know the elevation above sea level at which the fire is located.
Fires that occur at high altitudes are more demanding on
firefighters.
 How the fire will be attacked is important. The heavier the
manual labor that will be performed, the greater the need for
rehab operations.
5. Haz Mat Incidents
 Rehab must be established anytime CPC is being worn at an
incident.
 Rehab must be set up un the Cold (Green) zone
6. Warm Weather Situations
 The benchmark for establishing rehab due to warm weather will
vary depending on the normal conditions of that jurisdiction.
 Keep in mind that the thermal impact on firefighters includes
the ambient temperature, the humidity, PPE being worn, and
whether they are operating in direct sunlight.
 The temperature and humidity combine to form the heat index.
Add 10ºF for wearing PPE and 10ºF if operating in sunlight.
Consider rehab if the combination of all of these is above 90ºF.
 In severe conditions, require formal rehab after one SCBA
cylinder is used, instead of two.
7. Cold Weather Situations
 Initiate rehab based on local criteria and weather conditions
 Keep in mind that firefighters burn more calories in cold
weather.
 Rotate personal more frequently in severely cold weather.
8. Training Exercises:
4-6
4-7
4-8
4-9




Training exercises often involve strenuous work that continues
for extended periods of time, often a full day.
Firefighters in recruit academies can work at these levels for
multiple days on end.
All training classes or exercises should be designed so that rehab
will be available to the participants for appropriate amounts of
time at regular intervals.
When possible the rehab set-up and procedures used in training
should mirror those that are used in the field.
4-10
4-2
Describe where rehab operations fit into the Incident
Command System.
4-11
1. All incidents should be operated under the framework of NIMS ICS.
2. In a fully expanded ICS structure, Rehab is part of the Medical Unit,
within the Service Branch of the Logistics Section. There may be
other components in the Medical Unit on large incidents.
4-12
4-13
3. Few incidents ever are expanded to this extent.
4. On daily incidents Rehab will most likely report directly to the
Incident Commander or to the Operations Section Chief.
4-14
5. Make sure the accountability system being used incorporates the
Rehab Unit into it. You must account for responders who are in
Rehab.
4-3
Select an appropriate site to establish rehab operations.
1. Local SOPs should dictate who is responsible for selecting the
location of the rehab area. Could be:
 Rehab Group Supervisor
 Medical Unit Leader
 Logistics Section Chief
 Incident Commander
4-15
4-16
2. Two general philosophies on Rehab site location: close to the
Command Post and remote from the Command Post.
3. Rehab located close to the Command Post:
 Allows the IC to monitor personnel
 Allow command vehicles to be clustered
 Does not allow rehabbing firefighters to relax as much
 ICs may have a tendency to send folks back in too quickly
4-17
4. Rehab remote from the Command Post:
 Allows for more relaxation and decompression
 Allows more room for larger rehab operations
 Travel distance should not be too far
4-18
5. Three primary questions to ask when selecting a Rehab Area site:
4-19



The estimated number of people to be rehabbed? Small incident
may be handled with relatively few resources.
The climatic conditions at the time of the incident? Poor
weather may require a sheltered rehab area.
The expected duration of the incident? Long duration incidents
may require fixed facilities.
6. General rules of thumb for establishing Rehab Areas:
 Locate the rehab area in the incident’s “cold” zone.
 Be reasonable in the distance from the work area to the rehab
area.
 Choose a site that protects responders appropriately from the
weather conditions.
 Make sure the site is large enough to comfortably fit all those
people who will be rehabbing or operating the site.
 The site should be free of vehicle exhaust. If running vehicles
are a part of the rehab operation, they should be positioned so
that their exhausts discharge downwind of rehabbing personnel.
 Excessive, loud noise can have a negative impact on people’s
ability to relax and recharged. Look for as quiet a location as
possible.
 Make sure that you are able to restrict media access to the rehab
area.
 Apparatus capable of replacing and/or refilling expended SCBA
cylinders should be co-located at the rehab area (Figure 4.22).
 The rehab area must be easily accessible, in both directions, for
ambulances that may be needed to transport injured firefighters
to a medical facility.
 Rehab operations require substantial amounts of drinking water.
On smaller, shorter incidents these needs can usually be easily
met with drinking water that is brought to the scene on
apparatus. For long-term incidents it helps to have a rehab area
located in a location where a drinking water supply source is
available.
 It is helpful if rest room facilities are a part of the rehab area or
are in close proximity to it.
 Make sure the rehab area is remote from gruesome sights.
Relaxing firefighters should not have to view disturbing incident
conditions.
4-20
4-21
4-22
7. If multiple Rehab Units are established, they should be named
appropriately under ICS, such as the North Rehab Unit and South
Rehab Unit.
4-4
List the necessary components for a rehab operation.
4-23
1. When preparing to set up Rehab operations, the following basic
functions must be taken into account:



Physical assessment – Every firefighter must be given a basic
physical assessment when they first enter the rehab area.
Revitalization – The basic intent of this function is to provide
rest, rehydration, and nutritional support for responders who
have been actively participating in incident operations
Medical evaluation and treatment – Firefighters whose initial
4-24




assessment reveals present or pending injury or illness must
receive more thorough evaluation and treatment in order to
minimize the chance of their condition worsening (Figure 4.19).
Continual monitoring of physical condition – Firefighters who
are in either the revitalization area or the treatment area should
both receive continual evaluation during their stay in the rehab
area.
Transportation for those requiring treatment at a hospital –
Rehab SOPs must establish responsibilities and plans that
address how firefighters who need more intensive medical care
will be transported to a hospital.
Initial critical incident stress assessment and support – Incident
that require large rehab operations often involve situations that
can be emotionally stressing to firefighters. Most departments
that have well-developed CISM plans choose to implement them
as part of the rehab operation.
Reassignment – Each department will have their own procedures
on how to handle firefighters who been restored to acceptable
physical and emotional condition and are ready to be either
reassigned to the incident or sent back to their quarters.
4-5
4-6
Describe the types of facilities or apparatus that may be
used for rehab operations.
4-25
1. Three choices for locating a Rehab Area
 Fixed facilities
 Apparatus-based
 Portable shelter/open area
4-26
2. Fixed facilities are best for long incidents and large numbers of
personnel. Some keys to building selection are:
 Look for a structure that is reasonably close to the incident scene
and is easily accessible to the firefighters who will report there.
 Try to locate the rehab area on the ground level, if possible.
 Make sure the portion of the facility that will be used for rehab is
large enough to comfortably contain the people and resources
that will be located there.
 Facilities that have running water and restroom facilities are
highly desirable. On very long term incidents it is a bonus to
have suitable kitchen facilities as well.
 Facilities that are climate-controlled are helpful in extremely
cold or hot conditions.
 Try not to select structures whose use for fire department
operations will negatively impact the operations or finances of
the buildings occupants.
 Avoid structures in which the equipment worn and used by
firefighters may cause damage to the facility.
 Make sure that access to the rehab area can be controlled and
that civilians, media, and other nonessential personnel cannot
easily access the rehab area unchecked.
4-27
3. Apparatus-based operations are most common.
 Standard apparatus may be used for their equipment or shelter
on small incidents.
 Apparatus with SCBA refill capabilities should be located at
rehab.
 EMS transport capabilities must be present
 Canteen and special rehab apparatus obviously will be located
here
 May call for buses to be used as shelter in extreme conditions
4-28
4. Open area rehab operations
 May use portable shelters
 Look for protection from elements (sun, rain, etc.)
 Make sure it is easily accessible for apparatus, EMS vehicles,
and equipment deployment
4-29
List all of the types of equipment that may be used in
rehab operations.
4-30
1. Any or all of the following equipment may be used in Rehab
operations. Exactly which equipment will be used is based on local
preference and resources.
 Rehab Area Marking Equipment – Cones, tape, signs, etc.
 Tarps and blankets
 Portable shelters
 Portable heaters
 Misters/coolers
 Fans and blowers – Don’t use gas-powered
 Electric generators and accessories
 Lighting equipment
 Rehab recording equipment – For tracking firefighters while
they are in Rehab
 Extra PPE
 Portable toilets
 Hand washing equipment
 Chairs and tables
 Drink dispensing equipment
 Trash collection equipment
4-31
Section 5 – Caring for
Firefighters During Rehab
Operations
Objectives
Section
After completing this section, the firefighter will show the following competencies by
achieving an acceptable score, as defined by your organization, on the written test or by
any other means of evaluation deemed acceptable by the organization.
Specific
After completing this section, the firefighter will be able to: (Slide 5-1)
1. Explain the requirements for rehabbing firefighters.
2. Describe the rehab process, including self-rehab and formal rehab operations.
3. Provide medical treatment to firefighters in the rehab area.
4. Explain hydration strategies and dehydration concerns associated with rehab.
5. Select appropriate fluids and foods for rehab operations.
Time
30 minutes
Section 5 Outline
Introduction
Explain
that once a rehab area has been established, every effort must me made to ensure it is
run properly. Everything must be focused on the well-being the firefighters who are
being sent to the rehab area. Appropriately trained medical personnel must be available
to evaluate and treat (if necessary) personnel that report to the rehab area. Suitable
fluids and food must also be provided.
Discuss
incidents where the firefighters had both positive and negative rehab experiences and
ask them to explain why.
Review
the specific objectives you plan to cover in this section.
Objective
Outline
5-1
Explain the requirements for rehabbing firefighters.
Visuals
5-2
1. Each department must have and enforce an SOP that requires
responders to go to rehab before they are totally expended or
injured.
2. Everyone is responsible for their own conditions and must selfmonitor.
3. NFPA 1584 has the following requirements:
 The company or crew must perform self-rehab (rest with
hydration) for at least 10 minutes following the depletion of one
30-minute SCBA cylinder or 20 minutes of intense work without
wearing an SCBA. Following the self-rehab period it is up to the
company officer or crew leader’s to determine the readiness of
the other crewmembers to return to duty.

5-3
The company or crew must enter a formal rehab area, receive a
medical evaluation, and rest with hydration for a minimum of 20
minutes following:
o The depletion of two 30-minute SCBA cylinders
o The depletion of one 45- or 60-minute SCBA cylinder
o Whenever encapsulating chemical protective clothing is
worn
o Following 40 minutes of intense work without an SCBA.
4. The IAFF’s Thermal Heat Stress Protocol for Fire Fighters and
Hazmat Responders recommends a 30 minute work period followed
by 30 minutes of rest in a rehab area.
5-2
Describe the rehab process, including self-rehab and
formal rehab operations.
5-4
1. There are two types of rehab: self-rehab and formal rehab.
2. Self-rehab basically involves taking a break and rehydrating
yourself
 Usually done after expending one SCBA at an incident or short
periods of heavy work.
 Should be built into training ground evolutions and rotations
 Remove appropriate PPE
 Drink at least 2-4 oz every 20 minutes; more in extreme
conditions
 Should rest for at least 10 minutes
 Have other firefighters service the rehabbing firefighters SCBA
5-5
3. Drinks may be served in individual serving containers or from bulk
containers.
4. The company officer should determine when the crew is fit to return
to action.
5. Formal rehab areas are established on larger and extended incidents.
6. The number of people needed to run a formal rehab unit will be
dependent on a number of factors:
 The number of firefighters and other responders who will require
rehab services
 The duration of the incident
 The environmental conditions at the time of the incident (more
severe conditions will require more personnel)
 The condition in which responders accessing the rehab are in
when they arrive at the rehab area. The worse shape they are in,
the more people that will be required to care for them.
5-6
7. It is preferable for ALS-trained personal to be assigned to medical
function in rehab. EMT-B level trained people are required at a
minimum.
 EMS personnel treating people in rehab should not also be
responsible for transport.
8. Non EMS personnel may perform functions such as providing food
and drinks and replenishing SCBAs.
9. The first stop in rehab is the Entry Point/Initial Assessment Area.
 Everyone must go through this entry point and be logged in.
 Shed SCBA and PPE, if appropriate
 Should have vital signs checked and be observed for other
problems
 May be sent to the Treatment Unit or Refreshment Unit
depending on their condition.
 Send to the Treatment Unit if:
o Pulse is in excess of 120 bpm
o Body temperature is in excess of 100.5ºF
o Diastolic blood pressure is above 90 mmHg
o Systolic blood pressure is above 130 mmHg
o Showing signs of chest pains, shortness of breath, altered
level of consciousness, extreme fatigue, poor skin color,
and similar symptoms.
5-7
10. The Rest/Refreshment Unit has three responsibilities:
 Providing rest
 Providing fluids
 Providing nutrition
5-9
5-8
11. Rest/Refreshment Unit should be set up in a area appropriate for
conditions (cool area during hot weather, heated area in cold
weather).
12. The amount of time that each person must spend in
Rest/Refreshment varies on:
 The responder’s level of physical conditioning
 The atmospheric conditions
 The nature of the activities the responder was performing before
entering rehab
 The time needed for adequate rehydration and/or eating
5-10
13. Absolute minimum rest times (per NFPA 1584) are 10 minutes
after the initial assessment and 20 minutes if two SCBA cylinders
have been used or 40 minutes of heavy work has been performed.
14. Drinks and food must be served safely and in accordance with local
capabilities and procedures.
 Bulk drink containers are better for large incidents
 Food must be able to be served safely, especially if cooked
15. The Medical Evaluation/Treatment Unit is responsible for caring
for firefighters who are in need of treatment as determined in the
initial assessment.
16. The highest trained EMS personnel on scene should perform these
functions.
 Follow local EMS treatment protocols and start documentation
on each member.
 Allow members access to food and drinks, as appropriate
 Reevaluate after they have had sufficient time to rest/recover
17. There are only three possible dispositions for people who are sent
to the Treatment/Evaluation Unit:
 The responder responds appropriately to rest and rehydration
and is able to return to action or return to quarters. The person is
often moved from the Treatment Unit to the Rest and
Refreshment Unit before leaving the rehab area.

Standard, basic EMS treatment procedures are initiated and the
firefighter is monitored to see if the treatment corrects the
situation they are facing.

Advanced medical treatment, followed by transport to a medical
facility, is required. Make sure that any paperwork that is started
on the patient is transported to the hospital per local protocols.
18. The Transportation Unit is responsible for transporting firefighters
5-11
5-12
who cannot be properly treated or stabilized on the scene.
 The number of transport units needed will depend on the size of
the incident; one is the minimum
 Personnel working the Treatment Unit should not also be
responsible for transport
 The Transportation Unit Leader should verify hospital status
and determine where people will be transported depending on
hospital capabilities and patient needs.
 If one ambulance transports, replace it with another standby
unit.
19. The Reassignment Unit is responsible for releasing personnel from
the Rehab Unit. According to NFPA 1584, there are three basic
dispositions for personnel who have been assigned to the Rehab
Unit:



5-13
If they are in suitable condition they may be reassigned to
another function on the emergency scene.
If they are in good condition, but their services at the
emergency scene are no longer required, they can return to
service and be sent back to the station or home, as the case
may be.
If deemed necessary they can be transported to a hospital for
further evaluation and/or treatment.
20. The Reassignment Unit may be a single person on small incidents
or multiple people on larger incidents. Does not have to be an EMS
person if the Treatment Unit person was an EMS person.
21. If one member of a crew has been removed from service, the
following options are available to the Reassignment Unit Leader:

The remaining crew members may be paired up with another
group of firefighters and one crew leader can be designated for
the new crew.

The remaining crew members may be reassigned as a single
crew to a function that can be handled with the remaining
number of crew members.

If the member that did not return to service was severely injured
or is suffering from a serious illness, the remaining crew
members may need to be removed from service, particularly if
the crew members were involved in treating the victim.
5-14
22. Do not demobilize Rehab too quickly.
 Much of the most tiring work is at the end
 May scale down rehab unit size as responders are released from
the scene
 Maintain all capabilities, at some level, to the end
 Police the area for trash and medical supplies before leaving
5-3
Provide medical treatment to firefighters in the rehab
area.
1. This lesson does not provide definitive information on the treatment
of injuries. Local EMS protocols should be followed for these
procedures.
5-15
2. The most commonly encountered conditions that may require
treatment in rehab can be broadly lumped into four categories:




5-16
Traumatic injuries, such as cuts, bruises, burns, sprains,
fractures, and similar injuries.
Thermal injuries, such as heat-related illnesses, frostbite, and
hypothermia.
Stress-related illnesses such as heart attacks, strokes, or other
cardiac-related problems.
Respiratory illnesses related to exposure to heat, smoke, and
toxic gases or chemicals.
3. Traumatic injuries are the most commonly encountered
 These include cuts, sprains, strains, debris in eyes, etc.
 Thoroughly clean and wrap cuts and small burns
 Splint possible sprains or fractures and transport
 Do not allow person to return to the incident if their injury
could be made worse
5-17
4. Thermal injuries include heat and cold injuries. These were covered
in detail in Section 3 of this program.
5. Stress-related illnesses include psychological and physiological
stress. They are somewhat related.
5-18
6. Psychological stress in unavoidable due to the requirements of the
job. There are also potential long-term effects on the physiological
well-being of overly stressed firefighters that may manifest in a
variety of ways, including:

A decreased ability to mobilize the fight-or-flight response of the
sympathetic nervous system of the firefighter.

Increases or decreases in the firefighter’s appetite, either of
which can result in long term negative health consequences.

Suppression of the firefighter’s autoimmune system, resulting in
a reduced capacity to fight off common infections.

An alteration in the perception of the severity of pain
7. Make sure that firefighters are of good psychological health before
an incident occurs.
8. Provide proper CISM services, as needed, in the Rehab operation.
Follow-up as required after the incident.
9. Personnel working in rehab operation should be watchful for
5-19
rehabbing firefighters who are showing signs of suffering from
acute psychological stress. This stress can be manifested in a
variety of ways, but some of the following are the more common
ones:



Inappropriate levels of angry or aggressive behavior, in general
or directed towards other people
Obvious emotional symptoms such as crying, yelling, or a sense
of panic, often in an uncontrolled manner
Signs of being withdrawn, in a state of shock, or being depressed
10. The two most severe potential physiological stress illnesses that
may be encountered during rehab operations are heart attacks and
strokes
5-20
11. Heart attacks account for only 2% of firefighter injuries, but nearly
half the deaths
 Most commonly as a result of preexisting condition such as
coronary artery disease
12. While the range of symptoms for people suffering a cardiac
emergency are fairly broad, some of the most common ones
include:



5-21
Shortness of breath, beyond that of someone who simply has
been working hard and is tired.
Tightness in the chest or chest pain, often radiating to the back,
abdomen, or down one or both arms.
Unusually rapid, slow, or otherwise irregular pulse and/or the
sensation of heart palpitations.
13. Cerebrovascular accidents (CVAs), also called strokes, typically
result from the blockage of a cerebral artery in the brain.
14. Some of the more common signs and symptoms of stroke include:




5-22
Severe headache
Difficult, slurred, or lost speech ability
Facial droop
Weakness or paralysis on one side of the body, typically on the
opposite side of the body from any present facial droop
15. Any firefighter showing these symptoms should be treated
according to local protocols and transported.
16. There are two primary respiratory illnesses or emergencies
associated with fire emergency or training scenes, thermal injuries
and smoke inhalation.
 These are usually as a result of failure to wear an SCBA when
they should
17. Thermal respiratory injuries are usually very serious and require
immediate transport to an appropriate medical facility.
18. Smoke contains both irritants and toxins. The toxins are divided
into lung toxins and systemic toxins.
19. Lung toxins encompass a variety of different toxins present in
smoke that are highly irritant or directly toxic to the bronchial
5-23
mucosa causing airway inflammation.
 Symptoms of exposure to lung toxins may include a cough,
breathlessness, wheezing, and excessive bronchial secretions.
 These symptoms may start relatively soon after exposure to the
smoke and may continue to develop for up to 36 hours after
exposure.
 Adult respiratory distress syndrome or delayed pulmonary
edema may occur in severe cases of exposure to lung toxins.
20. Firefighters who breathe in smoke may also be exposed to a variety
of systemic toxins.
 These substances are absorbed into the firefighter’s entire body
system and can have serious and fatal effects on the person.
 The two most common systemic toxins associated with exposure
to smoke during fire fighting operations are carbon monoxide
and hydrogen cyanide.
21. Carbon monoxide (CO) is contained in relatively high amounts in
smoke from almost every burning material.
 Carbon monoxide is an asphyxiant in humans.
 Several other preexisting medical conditions will also increase a
firefighter’s susceptibility to carbon monoxide poisoning,
including hyperthyroidism, obesity, bronchitis, asthma, heart
disease, and alcoholism.
 Symptoms of a potentially mild exposure include headache,
nausea, vomiting, drowsiness, red/flushed skin appearance, and
poor coordination.
 Moderate or severe carbon monoxide poisoning causes
confusion, unconsciousness, chest pain, shortness of breath, and
coma.
5-24
22. Hydrogen cyanide (HCN) is released during combustion of
materials such as polyurethane, nylon and acrylonitrile.
 Hydrogen cyanide is lighter than air and is readily absorbed in
the lungs
 Hydrogen cyanide acts as a cellular asphyxiant.
 CNS signs and symptoms usually develop rapidly. Initial
symptoms are nonspecific and may be confused with CO
poisoning.
 These include excitement, eye irritation, headache, confusion,
dizziness, nausea, vomiting, and weakness.
 As HCN poisoning progresses, drowsiness, tetanic spasm,
lockjaw, convulsions, hallucinations, loss of consciousness, and
coma may occur.
 After systemic HCN poisoning begins, victims may complain of
shortness of breath and chest tightness.
 Because of the similarities with symptoms associated with CO
poisoning, hydrogen cyanide poisoning is often difficult to
diagnose in the field. Definitive diagnosis will have to occur in a
hospital setting.
5-25
23. Local protocols should be followed for treatment of any smoke
inhalation, however the following procedures may also be used:
 Give high flow humidified oxygen. If hypercapnia is secondary
to coma or respiratory insufficiency, intubation and ventilation
may be required.
 Early intubation should be considered if there is stridor or
5-26


respiratory distress. Consider immediate or early intubation if
there are facial or neck burns, erythema, blistering or edema of
the oropharynx.
If advanced life support personnel are available, start IV therapy
according to local protocols.
Transport the victim to an appropriate medical facility as soon a
possible. Preference should be given to trauma center and those
facilities that specialize in the treatment burn victims and
respiratory ailments. Treatment within a hyperbaric chamber
may be required in extreme cases.
5-4
Explain hydration strategies and dehydration concerns
associated with rehab.
5-27
1. Proper hydration is a key to firefighter wellness.
 60% of the human body is water
 The human body loses water through four basic means: in urine,
in stool, during exhalation, and through sweating.
 During periods of extreme work or when exposed to high
atmospheric temperatures, the majority of water lost from the
body is as a result of sweating.
 The amount a person sweats will vary depending on a number of
factors, including:
o The individual’s metabolism and level of physical fitness
o The level of exertion the individual is performing
o The atmospheric temperature the person is operating in
o The amount of clothing and protective equipment being
worn
 During periods of extreme exertion, some people may lose as
much as 1 liter (about 1 quart or 2.2 pounds) of sweat per hour.
5-28
5-29
2. Firefighters must monitor themselves for dehydration.
 Monitor urine output and quality
 A headache often occurs at early onset
3. In addition to water, electrolyte and carbohydrate balance must also
be maintained.
4. Electrolytes are essential for cell function.
 Include sodium, potassium, calcium, and magnesium
 They are lost in the same way and at the same time water is lost
 Firefighters who are taking diuretic medications, such as
Lasix®, will be especially susceptible excessive amounts of
electrolyte loss.
 Easiest way to replace electrolytes is with sports drinks.
5-30
5. Carbohydrates exist in two basic forms: simple and complex.
 Simple carbohydrates are sugars such as glucose, sucrose,
dextrose, lactose, and fructose that are found in variety of natural
foods, such as fruits, milk, processed sugar, and honey.
 Complex carbohydrates are molecules made up of three or more
sugars. Complex carbohydrates are typically found in starchy
foods, such as bread, pasta, and potatoes.
 The body has s limited ability to store carbohydrates.
 Medium to long duration incident will require carbo
replacements.
5-31
6. Firefighter should prehydrate as a regular practice.
 Drink at least 6-8 oz of fluids every 6 hours
5-32
 Monitor urine output. Dark or odorous urine is an indication that
fluid intake should be increased.
 Avoid excessive amounts of caffeinated beverages while on duty
or prior to training activities
 Excessive amounts of alcohol used within the previous 24 hours
often causes dehydration.
 If performing strenuous activities while on duty, such as
physical training or involved practical training exercises, make
sure to drink adequate fluids following these activities to restore
hydration levels in the event an emergency response occurs.
5-5
7. Rehydration is an important function of rehab.
 Should drink 2-4 oz minimum during self-rehab
 May drink considerably more in a formal rehab situation;
anywhere from 12 to 32 oz is common
 Do not drink so much that it makes you ill
 Severely dehydrated personnel may require an IV. They cannot
then return to operations
 Must continue to rehydrate even after leaving the scene
5-33
Select appropriate fluids and foods for rehab operations.
5-34
5-35
1. Rehab fluids can be dispensed from individual serving containers or
bulk storage containers.
 Each has advantages and disadvantages.
 Individual serving containers are best suited for small incidents;
bulk containers for large incidents.
 Drinking cups will be needed if using bulk containers.
 Make sure you have trash receptacles regardless of which
method is used.
2. There are three primary considerations when choosing appropriate
drinks for rehab operations: taste, tolerability, and nutritional value.
 Must be tasty so people will drink enough of it.
 Must be easily tolerable to the digestive system so they don’t
get sick or bloated; thin liquids (sports drinks) are better than
thick liquids (milk shakes).
 Should be nutritionally sound and replace electrolytes and
carbohydrates, as well as water.
5-36
3. There are a variety of suitable drinks for rehab operations.
 Water is always good; however it does not replace electrolytes
and carbohydrates. Other choices should also be available
 Coffee, tea, soda, hot chocolate, dairy products, fruit juices, and
high energy drinks (like Red Bull) are not good choices
 Sport beverages replace water, electrolytes, and simple
carbohydrates and are the preferred rehab beverage
 Some agencies mix these 50/50 with water
5-37
4. Food is usually only needed at incidents that will exceed 2-3 hours.
 May be needed sooner if it is late night/early morning and
responders have not eaten in some time.
 Short- to medium-duration incidents typically only require minor
nutritional support in the form of prepackaged foods and other
easy to serve and eat items.
 Long-duration incidents may require more substantial, meal-like
support operations.
5-38
5. Food may be provided by:
5-39
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
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Fire department canteen units
Independently operated canteen units (Red Crass, Salvation
Army, etc.)
Brought to the scene by department members, church groups, or
civic organizations
Commercial caterers – Common on very long duration
incidents, such as major wildland fires
6. There is a wide variety food that can be used.
 If all you have available is fast food that is better than nothing.
 Try to seek a balance of carbohydrates, fats, and proteins
 Short duration incidents where canteens are not available may
use things like fruits, doughnuts, candy bars, and energy bars.
 Agencies that have fully equipped canteen units tend to provide
food that is easy to prepare at the scene. These include things
such as hot dogs, hamburgers, egg sandwiches, cold cut
sandwiches, soups, stews, and similar easy to prepare and eat
foods.
 Full service, long term caterers typically provide three full meal
services per day.
7. Regardless of who is providing the food or what food is being
served, the following principles must always be followed for
incident scene food serving operations:






Firefighters should wash their hands before eating any foods at
the incident scene. If running water and soap are not available,
use antibacterial premoistened towelettes, waterless hand
cleaners, or hand sanitizers.
All food serving equipment must be sanitary and fully compliant
with local health department regulations.
All foods should be fresh and stored and served at appropriate
temperatures.
Fire departments should have preestablished agreements with
local grocery or food providers on how food will be provided
when needed and how it will be billed and paid for.
These operations can generate a significant amount of trash.
Provisions must be made for collecting and disposing of this
trash.
For medium and long term operations it may be necessary to
rotate out personnel and volunteers who are serving food. This
should be planned out ahead of time.
5-40
5-41
Section 6 – Post-Incident Rehab
Considerations
Objectives
Section
After completing this section, the firefighter will show the following competencies by
achieving an acceptable score, as defined by your organization, on the written test or by
any other means of evaluation deemed acceptable by the organization.
Specific
After completing this section, the firefighter will be able to: (Slide 6-1)
1. Describe the procedures for terminating a rehab operation.
2. Explain the elements of a critical incident stress management program that apply to
rehab operations.
3. Explain how to monitor postincident hydration and nutrition.
Time
15 minutes
Section 6 Outline
Introduction
Explain
that rehab functions do not necessarily stop when incident scene operations are
terminated. Personnel should continue to self-monitor themselves and also watch their
fellow members for signs of dehydration, illnesses or injury, or stress-related problems.
Discuss
types of incidents, or particular incidents that the firefighters have attended, where
critical incident stress may have been a concern.
Review
the specific objectives you plan to cover in this section.
6-1
Describe the procedures for terminating a rehab
operation.
6-2
1. The Rehab Unit Leader or Group Supervisor should continuously
monitor the incident and increase of decrease rehab resources as
required.
 Some of the hardest work is done by the small numbers of
responders at the end of the incident.
 Rehab resources can be scaled back as responders leave the
scene.
 All rehab functions must be able to be carried out until the end
of the incident.
6-3
2. There are several factors to evaluate when determining which
resources should be left within the rehab operation and which may
be returned to service:



It is imperative that the people who remain within the rehab
operation are qualified for the tasks that they will be expected to
perform.
Personnel who typically perform specialized functions within the
department, such as rescue or haz mat companies, but whom got
assigned to rehab function in this instance should be relieved
and/or replaced as soon as possible so they are available to
handle any responses that require their special capabilities.
When all other things are equal, those personnel who have been
operating in the rehab operation the longest should be the first
ones to be released from service.
3. Make sure the rehab personnel are also “rehabbed” before they leave
the scene
 Follow departmental SOPs for placing equipment in service and
disposing of extra food
 Make sure all trash is cleaned up before leaving the area.
 The rehab area should be cleaner after the incident than it was
before the incident
6-2
Explain the elements of a critical incident stress
management program that apply to rehab operations.
6-4
1. Critical incident stress management functions should be
incorporated into rehab operations.
 The duties and activities that firefighters routinely perform also
come with a heavy burden on the psychological well-being of
these individuals.
2. The goals of a comprehensive critical incident stress management
program are:
 To minimize the emotional impact of critical incidents on
6-5
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

emergency responders.
To increase fire fighters’ resistance and resilience to this type of
stress.
To prevent harmful effects following critical incidents by
working with response personnel at or near the time of such
incidents.
To prevent any chronic effects, such as post-traumatic stress
disorder, through the use of follow-up care and employee
assistance programs.
6-3
3. Effective management of critical incidents involves a
comprehensive approach to managing both incidents and the
resulting stressors.
 Benefits to the department may include:
o Decreased absenteeism
o Decreased physical ailments
o Increased morale
o Improved decision making ability from reduced stress
o Reduction of poor coping strategies (e.g., substance abuse)
o Longer retention of qualified personnel
o Reduction of psychological problems
6-6
4. A well-designed comprehensive CISM program is multi-faceted and
involves a myriad of interventional approaches.
 Assistance should always be offered in as informal a manner as
possible, depending on the needs of the company or individual
being assisted.
 Interventions near the time of the incident include the following.
o Informal discussion and support at the company level
o Defusing with a behavioral health professional or other
CISM team member
o Formal debriefing with a behavioral health professional and
other CISM team members
 Members requiring long-term care will do so under the care of
licensed mental health professionals.
 Realistically, only the earliest portions of the CISM program
might be carried out in a rehab setting. These include informal
discussion among members and defusing sessions with
behavioral health professionals or trained CISM team members.
6-7
5. Defusing activities are most common in rehab operations.
 Defusing is an informal process to reduce immediately the
pressure and anxiety surrounding a critical incident.
 Defusing is not intended to encourage responders to ventilate
feelings, but rather to provide some guidance about what to
expect, describe resources, and establish a presence that may
make future interventions easier.
 A defusing process must be guided by the needs of the
emergency response personnel.
 Often, reliable information about the outcome of an unknown
event, such as the condition of an injured fire fighter, is
sufficient to reduce anxiety in personnel still operating at the
scene.
6-8
Explain how to monitor postincident hydration and
nutrition.
6-9
1. Additional rest, fluid intake, and in some cases, food intake will be
needed after the incident to ensure that proper metabolic levels are
6-10
restored.
 It is generally recommended that firefighters drink an additional
12 to 32 ounces of electrolyte- and carbohydrate-containing
fluids within the 2 hours following the operation.
 One simple way to monitor if proper hydration has been
restored is to self-monitor one’s urine output.
 A properly hydrated person should have a reasonable volume of
urine output and that urine should be relatively clear and odorfree.
 Firefighters should also monitor themselves and their fellow
firefighters for signs of delayed medical problems following an
incident or training exercise.
 Serious medical conditions, such as heart attacks, strokes, and
other potentially fatal conditions can occur as long as 24 hours
following the activity.
 Seek medical attention immediately if any symptoms develop.